Elderly Woman Dies After Nurse Refuses To Give CPR

[haha]

I agree it is a difficult question - but to your quoted point, couldn't you say the same thing with regard to vaccines, antibiotics, or chemotherapy? Where do you draw the line?

Where it touches the speaker.

On the particular case of this patient, if she is guilty of nothing else, this nurse is guilty of colossally bad PR judgment. She likely was only trying to figure out what would be least likely to cost her a job. Another reason it is better to get anything you can afford by private, non-institutional channels. They work directly for you, not for their employing bureaucracy.

Ha

 

[Brat]

There hasn't been much discussion of what chest compressions do to an elderly woman. My SIL is in a care facility at this moment suffering from rib fractures from a fall at home, she doen't have a good quality of life. I would do mouth-to-mouth breathing until someone with 'paddles' arrived but chest compressions would not be kind.

 

[jclarksnakes]

Some people in their 80s are very happy to be alive.

My mother nearly died of a cardiac problem around that age, but was saved by surgery and is now leading a happy life, taking care of her granddaughters very often, etc. And I'm very glad she's still around.

I'll be turning 45 soon and can't imagine that I would ever want a DNR order, UNLESS my quality of life would become particularly bad. You can't deduce from someone's age that that person doesn't want to be alive as much as you anymore.

In much of the developed world people are living longer than in the past and staying healthy longer. And with medical progress that will hopefully improve even more in the future. I certainly hope people taking care of me in my old age won't assume I'm cool with dying and will do everything they can to keep me alive until I decide I myself that I want to die.

If I am alive in my 80s I will be VERY happy about it but that does not change the fact that CPR is almost always unsuccessful when performed on elderly patients. In this case the patient's daughter who is a nurse said that she was satisfied with the treatment her mother got. Of all the people posting on this forum there are probably only a couple who have participated in more codes than I have. I was usually the guy working up a sweat doing compressions. I worked nights in a teaching hospital and the senior residents often ran codes for extended times to train the medical students and junior residents. CPR was never anything like what you see on television. The very few elderly patients that survived CPR went into the ICUs and ended up on ventilators and always died there.

Edit to add: When we had codes one nurse would call the attending Physiican. We would keep them apprised of the progress of the code and they would sometimes tell the Senior Resident to stop the code. On one occasion I had a patient who was not a DNR arrest while the attending was there and she decided to not call a code. Nurses will sometimes talk about a "slow code" (waiting to make sure the patient is dead before calling a code) but I was never aware of that actually happening.

 

[ERD50]

The very few elderly patients that survived CPR went into the ICUs and ended up on ventilators and always died there.

Thanks for this perspective (I've heard it from other sources as well).

What's really bothering me is on the TV/Radio talk I keep hearing the 911 caller being vilified (paraphrasing) 'She had a moral obligation to save that woman's life, and she just refused'. They make it sound so cut and dried - do CPR, save the woman; don't do CPR, she dies. It's clearly not like that.

On one hand, I think the 911 operator did an excellent job in being persuasive and trying to get someone to give the woman CPR (regardless of whether that was a proper response). OTOH, if non-CPR is so typical in these places, I would think that 911 operators would be aware of this? I don't know, maybe their training can't go into that much depth, but there must be a lot of calls from these places, due to the age of the residents, so I'd expect them to be familiar with the protocols.

-ERD50

 

[Meadbh]

I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.

 

[growing_older]

Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.

 

[grasshopper]

I think I now know of a great tattoo. DNR, right over the old thumper.

 

[ERD50]

I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.

From what I've heard/read, the residents sign a document that states they accept that the facility does not provide CPR. Hopefully that's not buried in fine print, but they are agreeing to it if they sign.

Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.

Who is agreeing based on $? CPR has poor outcomes, esp for older people.

But the more expensive assisted care centers have more medically trained people around (and have to charge for it). These people might be in a better position to determine if CPR is appropriate or not for an individual. What can you expect? How about every older person living at home, or every person with a higher-than-average coronary risk profile be accompanied 24/7/365 by a trained EMT? Not really practical is it? Where do you draw the line? Those $ would be better applied elsewhere.

-ERD50

 

[donheff]

Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.

But many residents of asisted living would have DNRs on file and would not be resuscitated. I suspect many, if not most, require an advance directive upon entrance. For people who do not have a DNR, the very concept of assisted living means they have expectations of trained help readily available. From the various articles, residents of independent living sign agreements that they will not get CPR until EMTs arrive. I don't see any contradiction here.

 

[Midpack]

Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.

Some of us know individuals who are adamant about not being resuscitated. Difficult as it may be, some individuals choose facilities specifically because they feel confident their DNAR request will be honored. Glenwood Gardens Independent Living policies in place were published when this story first broke, they seemed very clear. The facility seems to be highly regarded if the online references before and after this story are any indication.

That said, there still seems to be some confusion about the exact circumstances in this case. If it's true as widely reported that her daughter was satisfied with the care her mother received, that carries far more weight than all the third party opinions floating around IMHO.

The elderly woman's passing is sad no matter what, 87 years old or not. And I don't think the nurse or the 911 dispatcher did anything wrong, they both did their best to fulfill their responsibilities from what I've heard. They were at cross-purposes, that doesn't necessarily mean either were at fault/to blame. YMMV

 

[JoeWras]

Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.

Looking at dad's contract (same company) I see nothing in black and white that says "no CPR by staff". However, it makes it clear that for all health care matters, the resident is responsible. Period. They have an emergency call system and that is clearly described as a system to forward 911 if necessary. They will make accommodations to hold the elevator, clear the way, and get access to the apartment for EMS.

Assisted living is another ballgame. It is licensed as a nursing facility. The rules are totally different.

We're 100% fine with these rules for Independent living.

I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.

Reading Dad's contract again. Recall, this is Independent living. Perhaps it is different on the assisted/SNF side.

Here they highly encourage residents to have advance directives and POAs, and if so, provide them confidentially to the staff for access. But they do not have a "rule". Again, I think that is in the spirit of independence.

 

[Stanley]

It must be great to be management. You tell a person such as a nurse, that they must do a certain thing in an emergency situation. She does it. When bad publicity surrounds it, its the nurse is headlined as the bad gal, while management's involvement (the real force behind the nurse's decision) is buried in the article.

 

[Brat]

It is unfortunate that the woman's physician did not talk to her about a POLST, she evidently didn't have that or a health care directive.

End-of-life care: an Oregon innovation helps people avoid unwanted interventions | OregonLive.com

 

[JoeWras]

Hopefully, some good will come out of this. I feel bad for the family being thrust into the spotlight. In any case, senior living companies have learned a lesson too and need to be forthright as to what kind and level of emergency care will be given. Sounds like management has reversed their initial stand on this case. In my Dad's place, it is very grey, yet still it would be understood that EMS was the first responder. It will be interesting to see if we get any correspondence on this issue.

What made this different was that it was in a common area. You'd have to consider this like if you had a heart attack at a restaurant, and a nurse was nearby. What would the nurse's obligation be?

"It was our beloved mother and grandmother's wish to die naturally and without any kind of life prolonging intervention," the family said. "We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace."
The family said it would not sue or try to profit from the death, and called it "a lesson we can all learn from."
"We regret that this private and most personal time has been escalated by the media," the statement said.

Read more: Family: Woman denied CPR wanted no intervention - SFGate
​

 

[rodi]

The more I read about this the more I wonder how the press learned about this. I assume it wasn't the family or the worker that reported it. So it probably came from the 911 operator.

Isn't that a violation of privacy?

To read that CPR in elderly patients almost always results in intubation... Yikes. My mom had a DNR but agreed to intubation for a surgery. Following the surgery she wasn't stable enough, so they left her intubated. She clearly wasn't happy about it but at that point the hospital would not remove it. In an ICU, they tie the patients hands down so they won't mess up the tubes/ports/IVs. The first time they turned their back with her hands not tied down, she extubated herself. (Which had to be awful!) Her first words croaked out were DNR!!!! (She died 12 hours later - but on her own terms.) My brother, who felt all measures *should* be used (anti-DNR?), tried to extubate himself when he was in the ICU, dying. He wanted exceptionally life saving measures, but hated being intubated. I conclude, that being intubated has to be one of the most unpleasant things possible.

 

[Meadbh]

The more I read about this the more I wonder how the press learned about this. I assume it wasn't the family or the worker that reported it. So it probably came from the 911 operator.

Isn't that a violation of privacy?

My thoughts exactly.

Yes, full resuscitation at the end of life can be very cruel. I have a pretty clear directive, which outlines the conditions under which I do not want to be resuscitated, the nature of the resuscitation, and even mentions that if I wake up and find that they have resuscitated me against my wishes, I and my heirs will sue the pants off them.

 

[Bikerdude]

I recently completed a CPR certification course. We practiced performing CPR on specially-equipped dummies that light up to show you whether the compressions are done correctly (hard enough). Most of us were pretty surprised at how hard we had to work (using both hands) to get it right. We were told that 80% of adults will suffer from broken ribs if the CPR is performed correctly.

I believe in my state you are held harmless if you administer CPR. As you said, done correctly, would will most likely break some ribs even on a young person never mind a frail 87 year old woman.

 

[Tigger]

CPR is almost always unsuccessful when performed on elderly patients.

Thanks, I had no idea. Looks like an interesting domain where there's room for progress.

 

[BarbWire]

There seems to be a lot of discussion of whether or not the woman had a DNR.

She was in California, but let's suppose she was in Texas, and she had DNR forms filled out, her physician had a copy, her family had copies, and so on. The problem is that, in Texas, a DNR applies only to in-hospital situations. In Texas, a standard DNR does not apply to nursing homes, assisted living facilities, the football stadium, the grocery store, or the individual's home.

If EMTs were summoned to assist her and she was not in hospital (and why would they be summoned if she were), then they are required to perform CPR, etc for 20 minutes unless rigor mortis has set in, or she has a different document, an "Out of Hospital DNR (OOH-DNR)" immediately available for the EMTs to find (which would mean she was at home -- because no one carries their DNR/OOH-DNR with them 24/7).

[side note: This is a heck of a good reason to have "VIAL OF LIFE" documents easy for EMTs to find, and to have the OOH-DNR on the top of the stack of papers].

A local EMT tech told me that if someone who does not want extreme measures has died (or is dying), then don't call the EMTs right away. Have "a final cup of coffee with Aunt Millie" so that RM can start (about 20-30 minutes) and thus the dignity in death and the wishes of Aunt Millie will be preserved.

And here's another twist: in Texas you can complete/sign a DNR without consulting your physician. It's your decision, right? But the OOH-DNR must be signed by the physician (in two places) and then signed by you and two witnesses, with those signatures notarized. Yeah, that's right: you've got to have your physician's permission to refuse extreme measures outside of a hospital. And physicians are very reluctant to sign the form, in case the wrath (or worse) of the family descends on them.

Texas makes it very hard for someone, like my 90-year old father, to die peacefully at home, according to his wishes.

 

[Katsmeow]

I found this article on the case interesting and it addresses a lot of the issues discussed in this thread:

Amid CPR Controversy, Many Unanswered Questions - NYTimes.com

To me, if she didn't have a DNR that was applicable then CPR should have been administered, end of story. Whether this is assisted living or not assisted living is irrelevant to me. Someone in this thread asked what if a nurse was a bystander in a restaurant (I think) and I think that a nurse or physician in that situation should administer CPR. I'm not saying it should be legally required, but I think that morally it should be done.

As to the deceased woman's child being satisfied with her mother not getting CPR, I guess my view on that is ....who gives a rat's posterior about anyone's opinion on that rather than the mothers. If it was me and I was the 87 year old and I wanted CPR in that situation then it is irrelevant to me if my daughter would be OK with me not getting it. What matters is the deceased person's wishes. And, since she didn't have a DNR we don't know what she thought. We know (from the article) what her daughter says the mother thought but there is no way to verify it. Lots of people just assume that everyone is elderly would want no CPR in that situation...but that may just be an assumption. That is why DNRs are in writing.

As far as doing CPR on an elderly patient. I would guess it depends. The NY Times article cites to an article on CPR in older patients:

How Successful Is CPR in Older Patients? - NYTimes.com

More on CPR for the Elderly - NYTimes.com

After reading the article, I found that there is a small chance of CPR being successful and there is a chance that the CPR will result in injury. That said, if I was otherwise in stable health (i.e. didn't have a terminal illness or dementia) and I was in my 80s I would want the CPR. And I wouldn't want someone deciding I would rather be dead than have broken ribs or that I would rather die than have a 9.4% chance of the CPR succeeding. (If was terminally ill or had dementia then I would feel differently).

The thing is that you can't know what someone would want just by knowing that the person is in his or her 80s. And, in the absence of a DNR I think you have to assume that the person would want the chance of CPR succeeding.

 

[JoeWras]

"Vial of Life" is what they should keep in the freezer. This is the standard place the EMTs are told to look. Thanks for mentioning the name.

Doesn't do any good if you drop in the dining hall, though.

I asked the question about the nurse witnessing this. Her refusal seems strange to me, yet I also understand somewhat having hung out in one of these places for a few weeks. I'm conflicted.

Finally, I want to say there is a difference between early and late 80's, in general. My observation has been that typically there is huge decline in this decade, and your DNR wishes are likely to change in this time. Of course, I speak generally. I met a few early 90's folks at Dad's place that were very vigorous and would probably not want a DNR.

Questions, questions and conflicts. These are not easy questions. We or our family will all face them some day, if we make it that far.

 

[donheff]

To me, if she didn't have a DNR that was applicable then CPR should have been administered, end of story. Whether this is assisted living or not assisted living is irrelevant to me. Someone in this thread asked what if a nurse was a bystander in a restaurant (I think) and I think that a nurse or physician in that situation should administer CPR. I'm not saying it should be legally required, but I think that morally it should be done...

if I was otherwise in stable health (i.e. didn't have a terminal illness or dementia) and I was in my 80s I would want the CPR. And I wouldn't want someone deciding I would rather be dead than have broken ribs or that I would rather die than have a 9.4% chance of the CPR succeeding. (If was terminally ill or had dementia then I would feel differently).

The thing is that you can't know what someone would want just by knowing that the person is in his or her 80s. And, in the absence of a DNR I think you have to assume that the person would want the chance of CPR succeeding.

Just goes to show why public policy should be very clear and people should make their wishes very clear. I would say the exact opposite of each of these points. If I saw a clearly very old (mid 80s+) person collapse on the street and stop breathing I would feel my moral obligation was to let that person die peacefully rather than jump in and do everything I could to insure they get to remain on tubes for a few extra months. Same for nurses and doctors who would more likely succeed in precipitating that unfortunate situation.

If I was in my mid 80s I would not want someone administering CPR. I wouldn't want someone deciding I would rather have the CPR succeeding and likely leaving me disabled, in a hospital bed, maybe even intubated for weeks instead of peacefully dying.

Texas' policy (described in a post above) sounds like the most intrusive, arrogant "do it our way or be damned" policy I can imagine.

 

[HFWR]

CPR: Less Effective Than You Might Think - Medical Myths - Harvard Commentaries | Aetna InteliHealth

For example, when a person has stopped breathing because of low body temperature (such as someone rescued after falling through ice into a cold lake) or another readily reversible condition, the success rate is higher. On the other hand, when an elderly person has stopped breathing because of heart problems or pneumonia, especially when other medical problems are present, CPR has a very low success rate.

 

[SumDay]

Heck, shouldn't DNR be the default policy in nursing homes? Heck, shouldn't DNR be the default policy in nursing homes?

I assure you, it is not. And even if you have one, it doesn't mean they'll honor it. Not in my state anyway, and especially not if the patient is private pay. They want to keep those hanging on for as long as they can. I had to threaten to sue to get my mother put on hospice. She was 92, suffered from a stroke that left her paralyzied from the waist down, and she had Alzheimer's and chronic heart failure. They insisted on submitting her to physical rehab every six months. I'm still pretty bitter about the whole thing. Good comfort care is one thing, but trying to "rehab" someone with all those issues was ridiculous. Someone please just shoot me when I get there.

 

[MikeD]

As a person who was "almost dead" and was considered in a state of "walking death" by my Internist of over 20 years (the quotes are what he said to my wife), I am wary of people's simplistic view of whether all people who are 87 should be left to die when they need CPR. I had terminal, end stage kidney failure and was fast approaching heart failure and had congestive heart failure. I felt absolutely horrible and felt like I was being poisoned. BTW, I know what it feels like to have Arsenic poisoning so I am not just making that up. I would not have wanted to be denied CPR just because I was a basket case. I very much wanted to live. I was pretty much cured of the kidney failure and heart failure and congestive heart failure overnight. I got a kidney and pancreas transplant in April, 1996. It literally saved my life. Before the transplant my BP was 250/125 and a day after it was almost back to normal. When the organs became available, I was second on the list but got the organs because the person who was first had the flu. The sickest person gets moved up the list the fastest. I was really, really sick. I was only on the list for four months. The usual wait is 4 years.

I am still pretty much a basket case of problems but I am not terminally ill anymore. If I get really sick because I am old and have no hope of getting better then I will get a DNR.

Deciding whether a person should have a DNR by default is crazy. Ignoring an old person having a CPR moment on the sidewalk because they are old is foolish. Resuscitate them and let them get a DNR for next time. If you let them die and they wanted to live then you've made an irreversible mistake.

Mike D.